Change and resistance to change in the NHS

The NHS is 50 years old. Every government since 1948 has re-invoked its founding principles, but there is less agreement about how services based on these principles should be organised. Alongside remarkable stability in the espoused purpose of the NHS there has been almost constant structural change. Health action zones and primary care organisations are the latest offerings. There is a paper mountain of advice on reforms, restructuring, and managing change. Yet many behaviours do not change. The puzzle is why the NHS has been so unchanging, given the barrage of attempts to “reform” it.

Some things have changed, of course, in as much as complex systems can be changed from outside. Bits have been knocked off and elements have been downsized or re-engineered, but these changes have been resisted by most “insiders.” These insiders have been successfully self ordering so that much of what happens in the NHS is unchanged in nature, if reduced in quantity. During all this investment in managing change, most insiders have not come to want the NHS to be different.

In this anniversary year it may not be enough simply to restate values and purpose. A more fruitful approach may be to focus on the behaviour of this complex system and to try to understand what creates the internal dynamics and maintains enduring patterns of order and behaviour.